Provider Demographics
NPI:1154115905
Name:CANTRELL, JENAE
Entity type:Individual
Prefix:
First Name:JENAE
Middle Name:
Last Name:CANTRELL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 MIKES PIKE ST
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047-2400
Mailing Address - Country:US
Mailing Address - Phone:928-289-6041
Mailing Address - Fax:928-289-8371
Practice Address - Street 1:700 MIKES PIKE ST
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-2400
Practice Address - Country:US
Practice Address - Phone:928-289-6041
Practice Address - Fax:928-289-8371
Is Sole Proprietor?:No
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLDO-002964156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician